Fungal Infections- Exam 2 Flashcards by Johannah Crumpton

______ common, normal flora that can become an opportunistic pathogen. What is the MC type?

Candidiasis

Candida albicans

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What are some risk factors for Candidiasis?

Chronic disease - chronic kidney disease, cancer, HIV, DM
Medications - corticosteroids, immunosuppressants, broad-spectrum abx
Vascular access - IV drug use, intravascular catheters
Other - recent surgery (especially abdominal), prolonged neutropenia, organ transplant

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Candidiasis of the _____ and _____ or the _____ are AIDS-defining opportunistic infections!

mouth

esophagus

lower respiratory tract

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______ often seen especially in infants, elderly, DM pts, immune deficiency, or after use of meds like antibiotics/steroids

Oral Candidiasis

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Beefy red, edematous mucosa of oral cavity
+/- white plaques on tongue, palate, buccal mucosa, oropharynx
Plaques can be scraped off with a tongue depressor
What am I?

Oral Candidiasis

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How is Oral Candidiasis diagnosed?

Often can diagnose clinically
KOH prep - budding yeasts, pseudohyphae
Culture - + for candidal species - more accurate, longer to results

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What is the topical treatment for oral candidiasis?

Nystatin (100,000 U/mL) - 5 mL (1 tsp) swish and swallow 4x/day
Clotrimazole troches (10 mg) - 1 troche dissolved orally 5x/day
Miconazole buccal tablet (50 mg) - 1 tablet applied QD

for 7-14 days

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What is the systemic treatment for oral candidiasis?

Fluconazole (Diflucan) 200 mg - 1 PO QD
May cut down to 100 mg after day 1

for 7-14 days

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What is the alternative treatment for oral candidiasis?

Gentian Violet x 3 days

usually commonly in babies

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Esophageal candidiasis is often seen in what type of pt population?

typically in HIV + or other severely
immunosuppressed pts; often also have oral thrush

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odynophagia, nausea, reflux, +/- oral thrush

What am I?

How do you diagnosis?

Esophageal Candidiasis

endoscopy

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What is the treatment for Esophageal Candidiasis?

Fluconazole (Diflucan) - 400 mg on day 1, then 200-400 mg daily for 14-21 d

Itraconazole (Sporanox) - if resistant to or intolerant of fluconazole
More costly, more nausea, must use solution rather than tablet

IV : Fluconazole (Diflucan) - 400 mg on day 1, then 200-400 mg daily for 14-21 d
If resistant to fluconazole - voriconazole, posaconazole, or an echinocandin

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itching, burning, and/or pain around genital area, dyspareunia. thick, white, nonmalodorous, “cottage cheese”. with NO ordor. very itchy

Vulvovaginal Candidiasis

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What are some risk factors that increase the rate of Vulvovaginal Candidiasis?

HIV, pregnancy, antibiotic use, uncontrolled DM all up the risk

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How do you diagnosis Vulvovaginal Candidiasis?

clinically!

can do KOH prep and culture but not normally

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Which vulvovaginal candidiasis treatment comes in ointment form?

terconazole (Terazol) so it stings less when applied

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What is the topical treatment for Vulvovaginal Candidiasis?

1, 3, and 7 day regimens available - rx or OTC
Miconazole (Monistat), clotrimazole (Mycelex), terconazole (Terazol)

NEEDS TO BE DOSED AT BEDTIME to prevent leakage

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What is the systemic treatment for Vulvovaginal Candidiasis?

Fluconazole (Diflucan) 150 mg - 1 PO x 1 dose
Ibrexafungerp (Brexafemme) 150 mg - 2 PO BID x 2 doses (300 mg q 12 hr)

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What is the prophylactic treatment for Vulvovaginal Candidiasis? Alternative?

Azoles - topical PV 1x/week or fluconazole 150 mg 1 PO 1x/wk
Probiotics - questionable benefit, but little harm

Gentian Violet x 1 application, Boric Acid PV x 7 days

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______ candida grows well in warm, moist environments (skin folds)

Candidal Intertrigo

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What are some risk factors for developing Candidal Intertrigo? Commonly seen where?

obesity, occlusive or tight clothing, sweating, incontinence, DM, immunosuppression, medications

beneath breasts, armpits, inguinal fold, pannus, diaper rash

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Erythematous, macerated, well-defined plaques in skin folds
Satellite erythematous papules and pustules
Well defined border with clear transition from red rash to non-effected skin

Candidal Intertrigo

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How do you dx Candidal Intertrigo?

clinically!!!
can do
KOH prep (skin scrapings) - budding yeasts, pseudohyphae
Culture - + for candidal species - more accurate, longer to results

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What is the treatment for Candidal Intertrigo?

Weight loss, controlling DM, wearing different clothing, etc.
Drying agents - talc, nystatin powder

Topical azoles or nystatin, BID until resolution (usually within 2 weeks)

systemic therapy if severe: Fluconazole 50-100 mg daily or 150 mg once weekly x 2-6 weeks

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Tinea capitis is found on the ____

scalp

tinea corporis is found on the ____

body (ringworm)

tinea cruris is found on the ____

groin (jock itch)

tinea pedis is found on the _____

feet- athlete's foot

tinea versicolor is found on the _____

body- pityriasis versicolor but is not a true tinea and is a dermatophyte

tinea unguium is found on the ____

nail- onychomycosis

superficial mycoses feed off ____. What will a KOH prep reveal?

keratin on the infected skin, nails and hair segmented hyphae

Single or multiple scaly, circular patches on scalp Alopecia; may see “black dots” at follicles (broken-off hairs) Patches slowly enlarge over time What am I? What pt population is it most commonly seen in?

Tinea Capitis primarily seen in children

How is tinea capitis dx?

clinically KOH prep and/or culture - usually only in ambiguous/refractory cases

pruritic, erythematous, scaling, circular or oval plaque Center of lesion clears, while a raised, advancing, scaly red border remains What am I? How is it spread? How it is dx?

Tinea Corporis- ringworm person-to-person and usually contracted from an animal clinical presentation, can do KOH prep and culture if unsure

____ is much more common in males. Asymptomatic or itchy Confined to groin and gluteal cleft Erythematous lesions with scaly, sharp, spreading margins; may have central clearing

Tinea Cruris

What are some risk factors for Tinea Cruris? How do you dx?

obesity, DM, immunodeficiency, sweating clinically KOH prep/culture

______ teens and adults especially males; seen often in athletes Spread by contact with spores shed from infected individuals Shared showers, locker rooms, floors around public pools May also have tinea cruris, tinea manuum, tinea unguium

Tinea Pedis

Acute exacerbations are self-limiting, but recurrent - often triggered by increased sweating Will continue indefinitely without treatment! Itching, burning, stinging of the toes and feet Erythematous bullae (acute) → scaling, fissuring, macerated skin, thickened plaques What am I? How do you dx?

Tinea pedis clinically KOH prep/culture

Where do you want to take a swab/prep from if you suspect tinea pedis?

on a not serious looking part May be falsely negative if taken from macerated skin

What are some risk factors for tinea unguium?

elderly, swimming, tinea pedis, immunocompromised, DM, psoriasis

thickened nail with yellowish or brownish discoloration; may separate from nail bed What am I? How do you diagnosis?

Tinea Unguium KOH prep and/or culture recommended to r/o other nail disorders

What is the treatment for tinea capitis?

*griseofulvin*, terbinafine; may consider fluconazole, itraconazole griseofulvin is first line but some peds dont use it because of the SE and labs that need to be monitored

What is the treatment for tinea corporis?

Topical - azole, butenafine, tolnafate, ciclopirox, or terbinafine QD-BID until cleared (1-3 wks) Systemic - extensive or refractory - griseofulvin, terbinafine, fluconazole, itraconazole

What is the treatment for tinea cruris?

Topical - azole, butenafine, tolnafate, ciclopirox, or terbinafine until cleared (1 wk); *medicated drying powders* Systemic - extensive or refractory - griseofulvin, terbinafine, fluconazole, itraconazole

What is the treatment for tinea pedis? What if it is macerated?

Topical - azole, butenafine, tolnafate, ciclopirox, or terbinafine If macerated - consider adding aluminum subacetate soaks 20 min BID Systemic - extensive or refractory - terbinafine, itraconazole, fluconazole, griseofulvin

What is the treatment for tinea unguium?

Topical - efinaconazole, tavaborole, or ciclopirox Systemic - *terbinafine*, itraconazole

_____ does NOT work on superficial mycoses infection aka tinea

nystatin only works on candiasis infections

______ candidemia; may be due to C. albicans or other strains. Severely immunocompromised state; nosocomial infection

Disseminated Candidiasis

Varies greatly - minimal fever to septic shock May see skin lesions ranging from pustules to nodules May involve liver, kidney, spleen, eyes, heart What am I? Dx? What is the treatment?

Disseminated Candidiasis blood cultures only + 50% of the time First line: IV Echinocandins Capsofungin IV Mild/moderate disease: fluconazole must continue for 2 weeks after their last positive blood culture

What is the MC fungal infection in the brown area?

Blastomycosis

What is the MC fungal infection in the yellow/gold area?

coccidioidomycosis

What is the MC fungal infection in the blue area?

Histoplasmosis

What is the MC fungal infection in the purple/pink area?

cryptococcus gattii

_______ inhaled spores from contaminated bird and bat droppings. Begins in lungs, but spreads throughout the body

Histoplasmosis

______ is caused by Histoplasma capsulatum

Histoplasmosis

Where is histoplasmosis commonly found?

Primarily in river valleys (Ohio and Mississippi River Valleys in US), but present worldwide

Fever, cough, myalgias, minor chest pain - almost never fatal Mild flu-like illness to severe pneumonia - 1 week to 6 months asymptomatic or mild; often found through incidental x-ray findings of pulmonary and/or splenic calcification; may see “eggshell” lymph node calcification

Histoplasmosis

_____ often in epidemics after soil with bird or bat droppings is disturbed. think moving dirt around on a construction site

Acute pulmonary histoplasmosis

In immunocompromised pts: Fever, cough, dyspnea, weight loss, prostration, oropharyngeal ulcers Multiple organ system involvement - hepatomegaly, splenomegaly, GI inflammation, adrenal insufficiency, bone marrow suppression, CNS infection Can have fulminant, septic shock-like presentation progressing to death without tx

Progressive disseminated histoplasmosis

What does the CXR of a pt with histoplasmosis look like?

Military infiltrates and mediastinal LAN

What are the 4 major forms of histoplasmosis?

Acute pulmonary histoplasmosis Chronic pulmonary histoplasmosis Complications of histoplasmosis Progressive disseminated histoplasmosis

Older pts with underlying chronic lung disease Pts are not necessarily immunosuppressed! What am I? What does the CXR look like?

Chronic pulmonary histoplasmosis apical cavities, chronic infiltrates, pulmonary nodules

_____ persistent mediastinal LAN and fibrosis of the mediastinum. Often seen in what condition?

Granulomatous mediastinitis Complications of histoplasmosis

Granulomatous mediastinitis Leads to compromise of pulmonary vascular structures Superior vena cava syndrome, esophageal constriction What am I?

Complications of histoplasmosis

What form of histoplasmosis?

acute pulmonary histoplasmosis with mild diffuse inflitration

What form of histoplasmosis?

Disseminated Histoplasmosis with diffuse interstitial alveolar infiltrates

What form of histoplasmosis?

NONE! its a normal CXR :)

What form of histoplasmosis?

Calcified healed Histoplasmosis (asymptomatic patient)

What is the dx?

Fibrosing mediastinitis caused by scar tissue from the histoplasmosis

What lab findings are common with histoplasmosis?

May see anemia of chronic disease, elevated LDH, ferritin, and/or AST

Chronic disease histoplasmosis would want to order a _____

sputum culture

disseminated histoplasmosis would want to order a _____

blood culture

What is the most accurate diagnostic study for histoplasmosis?

bronchoscopy with biospy

What is the treatment for mild/moderate histoplasmosis?

itraconazole (Sporanox), 200-400 mg/day (divided into BID dosing) weeks to months

What is the treatment for severe histoplasmosis?

IV amphotericin B Granulomatous/Fibrosing Mediastinitis: may try itraconazole +/- rituximab, +/- steroids and often times needs surgery

______ Coccidioides immitis or Coccidioides posadasii AKA “Valley Fever”

Coccidioidomycosis

_____ is transmitted through inhaled spores Grows in arid soil - southwest US, Mexico, Central America MC - immunocompromised, elderly Suspect in patients who live or work in endemic areas

Coccidioidomycosis

What is the incubation period of Coccidioidomycosis?

10-30 days

fever, chills, fatigue, HA, cough, myalgia May see arthralgia and joint swelling (especially knees and ankles) Rash (erythema nodosum) - may appear 2-20 days after s/s onset What am I? What does the CXR look like?

Coccidioidomycosis *infiltrate*, cavities, abscesses, nodules, bronchiectasis - persist in 5%

0.1% of white, 1% of nonwhite patients Filipinos, blacks, *pregnant women*, and immunosuppressed at especially high risk Worsened pulmonary s/s - mediastinal LAD, cough, increased sputum, lung abscesses Multiorgan involvement - skin, bones, pericardium/myocardium, meningitis Fungemia is possible; usually followed rapidly by death What am I? What does the CXR look like?

Disseminated coccidioidomycosis *localized infiltrate*, thin-walled cavities, pulmonary abscesses, nodules, mediastinal LAD, pleural effusion

What is erythema nodosum secondary to ?

Coccidioidomycosis infection

What is this? What is the underlying cause?

Erythema Nodosum secondary to Coccidioidomycosis infection

What does the CXR look like on a pt with Coccidioidomycosis?

patchy, nodular and lobar upper lobe pulmonary infiltrates are MC

What is the most reliable way to dx Coccidioidomycosis?

with biopsy and culture - most reliable method

What additional labs might be positive with Coccidioidomycosis?

-may see leukocytosis, eosinophilia May test for IgM and IgG complement fixation titer; possible to have false negatives

What is the treatment for mild/moderate Coccidioidomycosis?

fluconazole or itraconazole for 4-12 weeks May try voriconazole, posiconazole if refractory

What is the treatment for severe/disseminated Coccidioidomycosis?

IV amphotericin B x 2-3 weeks, then switched to azole Abscesses may need surgical management

When would you treat someone prophylaxis for Coccidioidomycosis?

AIDS pts with CD4 count <250 will require maintenance therapy with an azole to prevent relapse

______ inhaled spores found in moist soil with decomposing organic matter (wood and leaves) MC seen in men infected during outdoor activities for occupation/recreation South central and midwestern US and Canada Often occurs in immunocompetent (normal) pts

Blastomycosis

______ is caused by Blastomyces dermatitidis

Blastomycosis

chronic pulmonary infection Flu-like - cough, moderate fever, dyspnea, chest pain Extrapulmonary involvement - nodular, wart-like skin lesions S/S may resolve or progress to pneumonia-like illness purulent sputum production, pleurisy, fever, chills, wt loss, prostration What am I?

Blastomycosis

Blastomycosis is asymptomatic in about ____ of cases?

50%

Disseminated Blastomycosis is commonly found in ______ populations. Name some s/s

immunocompromised pts Bone - ribs, vertebrae MC affected GU - epididymitis, prostatitis, bladder irritation Skin - may see nodular lesions as above

In a urine antigen test, ____ has cross reactivity with Histoplasma

Blastomycosis

What does the CXR look like in Blastomycosis?

airspace consolidation or masses are most common

What labs finding are consistent with Blastomycosis?

may see leukocytosis, anemia

Should also order ____ and _____ with blastomycosis

sputum cultures; blood cultures if disseminated Bronchoscopy - with biopsy and culture

What is the treatment for mild/moderate blastomycosis?

itraconazole (Sporanox) for 2-3 months

What is the treatment for severe/CNS involvement blastomycosis?

IV amphotericin B

____ are inhaled spores found in soil and pigeon dung. Clinically significant disease almost always in immunocompromised pts

Cryptococcosis

Cryptococcus neoformans is commonly found ____

worldwide

Cryptococcus gattii is commonly found ______

tropical regions and Pacific NW

Of the cyrptococcosis varieties _____ may be more likely to infect immunocompetent and more likely to cause severe disease

C. gattii

**____ is the MC cause of fungal meningitis

Cryptococcosis

ranges from mild to respiratory failure May see simple nodules or fever, cough, dyspnea, widespread infiltrates

Pulmonary Cryptococcosis

HA followed by altered mental status, fever, CN abnormalities Meningeal signs - often absent, especially in HIV+

cryptococcosis meningitis

nodular lesions that may mimic bacterial cellulitis is often found in immunocompromised pts with _____

Cryptococcosis

If you suspect Cryptococcosis want to order ????

serum: test for cryptococcal antigens Cultures - sputum, blood, and/or urine cultures may be helpful Bronchoscopy - with culture of sputum CSF - budding, encapsulated yeast; + cryptococcal antigen

What is the treatment for pulmonary Cryptococcosis?

fluconazole (Diflucan) for 6-12 months HIV patients need continued suppressive therapy

What is the treatment for Cryptococcosis meningitis?

IV amphotericin B plus flucytosine (if tolerated) x 2 weeks Followed by 8 weeks of fluconazole Frequent LP or CSF shunting to relieve high CSF pressure if needed

_____ believed to have airborne transmission Most individuals have had asymptomatic infection by a young age Major patterns of clinical infection: Epidemics among premature or debilitated infants in underdeveloped countries Sporadic cases among older children and adults with impaired immunity HIV/AIDS patients

Pneumocystosis Pneumocystis jirovecii (worldwide

P. carinii is now called _____

Pneumocystis jirovecii aka Pneumocystosis

_____ abrupt onset of fever, tachypnea, SOB, nonproductive cough May or may not have bibasilar crackles on exam Spontaneous pneumothorax is possible Rapid deterioration and death if not treated

Pneumocystosis

CXR will have diffuse interstitial infiltration; may also see consolidation, nodules, cavitations (5-10% of pts have normal xray) NO CULTURES!! Bronchoscopy - with special testing of respiratory specimens Giemsa, methenamine silver, PCR, monoclonal antibody testing

Pneumocystosis

What is the treatment for Pneumocystosis?

TMP-SMZ (Bactrim) is the drug of choice - x 14-21 days HIV patients with CD4 <200 need continued suppressive therapy

What is the 2nd line treatment for Pneumocystosis?

primaquine/clindamycin, trimethoprim-dapsone